International Surgical Mission Goes to Philippines

Michael A. German, MD, UC Irvine Department of Otolaryngology The girl was 16 years old and had spent most of her life hiding smiles behind the back of her hand. She had never used a straw or whistled. She was born with a cleft lip and during adolescence had developed a large thyroid goiter that stuck out of her neck like a softball. Like many others, she had traveled miles across the island of Samar for an operation. We were privileged to help. February 4-18, I traveled with a group of surgeons and volunteers to Samar, a remote island in the Philippines. After three days of travel, including nearly 18 hours of flights, a van ride, and a river crossing by motor canoe, we arrived in Laoang, a crowded fishing and farming town of 80,000 inhabitants. We were to spend nine days there seeing patients and operating in the local hospital, Dr. Gregorio B. Tan Memorial Hospital, Kahundit St. Brgy. SMH. Planning was simple: bring the supplies, be flexible, and the patients will come. The mayor, who arranged for our daily food and accommodations, graciously welcomed us. After meeting our hosts, we walked to the district hospital. The layout of the hospital was in theory similar to facilities in the United States, with a central registration and waiting area, emergency department, operating room, separate wards for men, women, and children, and a small clinic. In reality it was a weathered, open-air concrete structure that blurred lines between jungle and hospital. A resident dog roamed the halls begging for scraps and a family of cats lived on one of the beds in the female ward. Geckos and spiders the size of my face hid behind piles of molded scrubs and rusty instruments piled up in the pathology lab. You soon realized in this setting that it’s the people who are at the core of healthcare delivery. As one of my mentors likes to say, “a poor craftsman blames his tools.” This was my second medical mission trip to the Philippines. Last year I went to a different town on Samar with the same organization. As a chief resident, I was determined to return to the Philippines this year to make the most of my skills and to follow up with some previous patients. I was fortunate to see a woman from last year with papillary thyroid cancer on whom we performed a hemi-thyroidectomy and radical neck dissection. It wasn’t safe to operate on both sides of her neck and place bilateral internal jugular veins at risk. I was delighted to see she made her way back to us even though we were in a different town many miles from her home. We were able to complete her thyroidectomy without complication and found no signs of recurrence since the prior surgery. I discovered that to a certain degree, continuity of care is possible even without Internet, reliable mail, and during many months and thousands of miles. I had been haunted by this particular case for the past year, wondering if we had done the right thing by operating on this woman. A year ago, we had given her and her husband some money to go to Manila for a completion thyroidectomy. Not surprisingly, they never went. I did receive an email from the local doctor with a picture of her about six months after the initial surgery and she looked to be doing well. Only now, more than a year after meeting her, I can feel confident that we helped her. There were also patients we could not help. We met a woman with an advanced-stage erosive mandible tumor, probably a sarcoma, which was inoperable even by U.S. standards. I had to explain to her that she had at most three months to live, even with radical treatment. She understood and was appreciative in spite of what little we could offer. There were other patients with diseases too advanced for the level of care we could provide. We had no ICU, no ventilators, and generally no means of administering critical care. Recognizing the inherent limitations of medical mission work is something that I have come to accept. In the future, I plan to continue mission work. As the world grows, there will only be greater need. I’ll also encourage and facilitate future residents to participate in mission trips. They provide for broader training, understanding healthcare in Third World countries, and exposure to pathology not seen in the United States. The commitment by our Academy to humanitarian work should be applauded. Operations Performed Parotidectomy – 4 Thyroidectomy – 9 Cleft lip repair – 8 Submandibular gland excision – 2 Maxillectomy – 1 Cystic hygroma excision – 1 Radical neck dissection – 1 Other mass excision – 4 Lessons Learned in the Philippines Not all dogs are friendly dogs. Always take a change of undershorts. Roosters warm up for sunrise at 2 am. The United States doesn’t have true reign. Expired lidocaine does not work. Be thankful for everything you have, because others may never have any of it. Suitcase wheels are good for about three miles in the Third World. Ibuprofen is a good pain medication and won’t cause bleeding. Suction, cautery, and electricity are overrated. At its core, the practice of medicine is, and always will be, about helping others—nothing more, nothing less.